6.3 Case Analysis
52 years old，female.She was admitted to hospital in March，2005 for“discovering a right breast lump in March”.History：1982 operated“double-sided ovary excision”，2002 operated“uterine total ectomy”.Check body：right breast top and a size of about 4cm×4cm×3.5cm，not clear boundary，solid，poor activity，see 0.8cm×0.9cm skin adhesion range.The right armpit touches 2.5cm×2.0cm swollen lymph nodes，fusion and activity.Left breast and left armpit，double-sided collarbone lymph nodes（-）.Ultrasound：A substantial occupancy lesions in the right breast，considering the possibility of breast cancer（see Fig.3）.Target：Right breast cancer，invasion and skin，consider lymph node metastasis（see Fig.4）.
Fig.3
Fig.4
Treatment：
Right breast lump hollow needle puncture：cancer，consider leaching catheter cancer，ER（+++），PR（+），CerbB2（+），Ki-67（-）.
Diagnosis：Right breast-immersed catheter cancer cT2N2M0 PHASE ⅢA.CTF chemotherapy three cycles（specific dose：CTX 0.8 d1+THP 40mg dl，2+5-Fu 0.75 dl-3），evaluated PR.Right breast cancer modified radical mestectomy（Ⅱ type）.
Disease examination：right breast section 1cm lump，leaching catheter cancer，armpit lymph nodes 3/16 see metastasis，ER（+），PR（+），CerbB2（+），Ki-67（-）.Diagnosis：Right breast-immersed catheter cancer ypT1N1MO ⅡA stage.Postoperative CTF chemotherapy for three cycles（specific dose：CTX 0.8 d1+THP 40mg dl，2+5-Fu 0.75 dl-3）.
Radiotherapy：DT 5000 cGy/25 times/5W on the right chest wall and right collarbone.
Endocrine therapy：Anaquator three years.
Review：No apparent recurrence，metastasis.
Diagnosis and treatment basis：According to the 10-year analysis of the Breast Cancer Clinical Trialcollaboration Collaboration Group（EBCTCG），the risk of recurrence and specific death from breast cancer is less and has significant benefits compared to traditional CMF.（Absolute gains of 3.4%and 4.3%respectively over 10 years）.Chemotherapy based on cyclocyclic drugs remains one of the current standard treatments（see Fig.5）.For postmenopausal breast cancer patients，a 5-year AI is better than TAM after all treatments（see Fig.6-8），according to the ATAC study.
Fig.5
ATAC研究设计
Fig.6 ATAS Research Winer，EP.J Clin Oncol.2002V20N15：3317-27
Fig.7 Anaquzole vs tamoxifen comprehensively reduces the risk of breast cancer recurrence
Fig.8 ATAC study：For patients with both get benefits breast cancer who are sensitive to postmenopausal hormone therapy，anaquator and TAM both get benefits regardless of the state of the lymph nodes and the tumor size.
（1）Bone metastasis therapy（after 3 years）：September，2008
SPECT Tip（+）
Diagnosis：Right breast-immersed catheter cancer，bone metastasis rT1N1M1 phase Ⅳ.Treatment：azolic acid and anacursion.
Regular review：SPECT prompts that the transfer stove is stable.Assessment：SD.Treatment：azolic acid and anaquzole（see Fig.9）.
Fig.9
See treatment in Fig.10
Fig.10 CSCO Breast Cancer Guidelines on Bone Metastatic Treatment
（2）Transfer progression therapy January，2011
SPECT：The upper ratchet-like radioactive increase in the left side of the tibia increased and increased from the previous advance（see Fig.11）.
CT：1.The density of the upper echidna after the left side of the shin increased unevenly，and the upper edge density of the left-hand joint increased，which increased compared to the previous lesions.
2.The left part of the L5 vertebral body and the density of the vertebral arch root are not uniformly increased，and the metastasis may be possible（see Fig.12）.
Assessment：PD
Treatment：isimetan and sic acid
Fig.11
Fig.12
（3）Bone metastasis progression therapy September，2012
Outpatient SPECT Tip：Right side of the upper cervix，lower cervical vertebrae，left 4th rear rib，4th lumbar spine right side metabolism increased，considered as metastasis，compared to the new lesions.
Assessment：PD(https://www.daowen.com)
Treatment：TAM or fluorovirus？→TAM
（4）Treatment of bone metastasis with TAM，2012-2016
May，2013 SPECT：Compared with the body bone image on September 4，2012：no significant change in the abnormal lynostic hyperplasia of the upper side of the original right side of the upper side of the upper side of the stoic，and the decrease in the abnormally radioactive increase shadow of the original lower cervical vertebrae and the 4th rib spot on the left side（see Fig.13）.
March，2016 SPECT：No significant change in the abnormal radioactivity of the original lower cervical vertebrae，considering benign；
Fig.13
Fig.14
（5）Second primary tumor
Review in March，2016
Ultrasound：1.Left breast sub-quadrant 6 o'clock direction substantive occupancy lesions（8×13×7mm），nature to be checked，ultrasound contrast tip：BI-RADS：5，consider the possibility of mammary Ca，recommended medical examination.2.Left breast outside the lower quadrant 5 o'clock direction substantive occupancy lesions 11×12×4mm，nature to be checked，ultrasound contrast tip：BIRADS：4C，can not completely except mammary Ca，recommended medical examination.
Check body：right breast deficiency，left breast is not significant lyummy，double-sided armpits and obvious lymph nodes.
Left breast quadrant 6 o'clock direction lump puncture test.The results of the post-puncture examination are shown in Figure 15.
Diagnosis：Left-breast-immersed catheter cancer cT1NOMO IA stage.
Fig.15
March 14，2016 Left breast cancer monomastectomy+left armpit outpost lymph node biopsy.
Postoperative pathology：disease detection：left breast-immersed catheter cancer，outpost lymph nodes 0/4 did not metastasis，left breast quadrant 6 o'clock directron lumps：ER（-），PR（-），CerbB2（3+），Ki-67（+，20%）.The lower left breast outside quadrant 5o'clock direction lump：ER（-），PR（-），CerbB2（-），Ki-67（+，1%）.FISH：HER2 gene amplification（see Fig.16）.
Diagnosis：Left breast-immersed catheter cancer pT1NOMO IA stage
Fig.16
Treatment
Yew alcohol liposome 255mg and Herceptin 512mg X 1 cycle
Yew alcohol liposome 255mg and Herceptin 384mg X 5 cycles
Review SPECT：Bone metastasis is better than before（see Fig.17）
Out-of-hospital maintenance therapy：Herceptin 384mg 1 year
Fig.17
（6）Liver and bone transfer（December 26，2018）
December 26，2018 Review CT：Multiple low density lesions in the liver，up to 1.9cm（right lobe of the liver），high probability of metastasis.SPECT：Multiple bone transfer.Ultrasound：Multiple substantial occupancy lesions in the liver，up to 2.5cm（left liver leaf），metastasis possible.
CT，MRI：Density is uneven in several thoracic vertebrae，ribs，jaw bone，the possibility of transfer is large.
Fig.18
Metatosis diagnosis：
Hepatic lesions puncture under the guidance of ultrasound，disease detection：liver biopsy see adenocarcinoma tissue，in line with breast cancer liver metastasis，ER（about 85%strong+），PR（about 85%+），Cerb B2（1+），FISH（-），Ki-67（+，60%）（see Fig.19）
Assessment：PD
Diagnosis：1.Right lactation catheter cancer，bone metastasis rT1N1M1 Phase Ⅳ
Left breast-immersion catheter cancer，liver metastasis rT1NOM1 Phase Ⅳ
Fig.19
Treatment：
Niobium acid and fluorovis group，at the same time recommend to use CDK4/6 inhibitors.March 16，2019，patients complain of pain in the liver area，pain in the whole body bone joint shortened，no nausea，vomiting，no yellowing of the skin sclune film（no related examination）-March 16，2019：Plus Palbolibcic，so far：pain in liver and bone has relieved and interval lengthened.
（Shicong Tang，Rong Guo，Rui Liu）